After decades of conflict and human rights abuses, reproductive health care in eastern Burma is among the worst in the world. Millions of women still inside Burma as well as those who have fled to neighboring Thailand face a perfect storm of devastating health consequences from lack of access to family planning and safe, legal abortion.

In Burma, abortion is only legal to save the life of a pregnant woman. And although abortion is legal in Thailand in some circumstances, women from Burma living in Thailand as refugees or migrants are generally unable to access safe abortion care. As a result, unsafe abortion is a major contributor to maternal mortality and morbidity on both sides of the Thailand-Burma border.

Reproductive health efforts have been undertaken by non-governmental organizations and community-based organizations in this region for decades. However, these efforts are often fragmented and lack coordination. In addition, few organizations address the issue of unsafe abortion beyond advocating for more family planning. In 2010-2011, a team of researchers from Ibis Reproductive Health and the Global Health Access Program conducted a comprehensive health assessment in order to understand abortion practices, harm to women, and ways to reduce the impact of unsafe abortion in this longstanding conflict setting.

Last week we formally released the report, Separated by borders, united in need. Our findings show a severe lack of access to family planning and considerable harm from unsafe abortion. Lack of health education and information contribute to high rates of unintended pregnancy, particularly among adolescents. Women have difficulty accessing family planning services and organizations report lack of contraceptive supplies. There is widespread misinformation among health workers about the legal status of abortion and referrals for legal and safe services within Thailand are rare. A lack of trained providers and restrictions on travel also prevent women from accessing safe, legal treatment.

As the world directs its attention to Burma and the possibilities for political change, it is important that we not forgot women and women’s health. The sixty-year civil conflict in Burma and has had a significant impact on reproductive health. As Burma embarks on its journey toward political reform, donor funds are likely to flood into the country. We must remember to target some of those resources to women’s health so that women can fully participate in political and economic opportunities to come.

Burmese seek help from illegal clinics

TAK : Mae Sot district is struggling to curb a rising problem of illegal and unsafe abortions among migrant workers.

Mo Mo Aung, a Burmese worker in the district, said a friend of hers, an illegal immigrant at a sewing factory, almost died as a consequence of an illegal abortion recently.

Her employer did not allow the woman to visit the doctor even when she suffered bleeding as a result of her abortion.

She had entered Thailand illegally and her employer feared he could be arrested if police heard about it, she said.

Her employer eventually took her to the Mae Tao humanitarian clinic at Mae Sot on the Thai-Burmese border, which is flooded daily with hundreds of Burmese refugees seeking medical attention.

They waited until a Sunday, when the streets of Mae Sot are busy, and authorities find it harder to detect illegal Burmese workers, she said.

Mo Mo Aung said she had known many Burmese women who crossed the border into Thailand because they wanted to end unwanted pregnancies. Some of the women had died as a result of the unsafe abortions.

Aye Aye Min, another Burmese worker in Mae Sot, said Burmese women usually sought advice about illegal abortion clinics from each other.

Ma Ma Aye, 28, a Burmese worker who has set up a group called “Yaung Chi Oo Worker Organisation” said many women end up going to an illegal abortionist because they were not ready to raise families.

Her group provides counselling to Burmese workers who are pregnant but do not want to keep their babies.

Burmese workers also turn to the Ruam Jai community, one of about 20 Burmese communities in Mae Sot, when they want help with unwanted pregnancies.

The community is a cluster of two-storey wooden row houses packed with Burmese tenants.

A number of non-profit organisations work there to help migrant workers.

One non-governmental organisation worker, who asked not to be named, said the cost of an illegal abortion in Mae Sot ranges from 1,000 baht to 4,000 baht, depending on how advanced the pregnancy was.

When complications occur, the women are sent to the Mae Tao clinic run by Dr Cynthia Maung.

Tawisa Amphong, a staff member at Mae Sot Hospital, said the hospital treats about 100,000 Burmese workers and ethnic minorities a year, but only 20,000 have a work permit.

The hospital had to meet expenditure itself of about 50 million baht a year treating this group, as the state did not want to pay medical expenses for illegal workers, said Ms Tawisa. Many women did not want to claim for them anyway, as their identity would be exposed.

The most common diseases found in Burmese patients were malaria, tuberculosis, elephantiasis, and Aids.

About 1000 pregnant Burmese women turned up seeking treatment every year, including those who suffered complications of unsafe abortions.

Patthini Suanprasert, a coordinator with the Mae Tao clinic, said 5,000 Burmese mothers registered for pregnancy care at the clinic every year.

Some returned with complications associated with substandard or illegal abortions such as internal bleeding and womb infections, said Ms Patthani.

Following the discovery of more than 2,000 aborted fetuses at a temple crematorium in Bangkok last week, Thai police have promised a crackdown on clinics performing illegal abortions, already arresting one abortion practitioner and investigating several clinics. The nascent crackdown immediately sparked criticism from reproductive-rights activists, who say it will force poor women into even more illicit and unsafe conditions if they choose to end a pregnancy in Thailand, where most abortions are illegal.

Police, who were called to the Phai Ngern Chotanaram Buddhist temple in Bangkok last Tuesday after neighbors complained of a foul odor, initially discovered 348 fetus remains wrapped in small plastic bags. After arresting an undertaker and a health-clinic worker, over 1,500 more fetuses were found on Thursday. According to the English-language Bangkok Post, the undertaker told police the temple’s crematorium had broken down a month ago, and so the fetuses had not been burned. The gruesome discovery shocked the temple’s neighbors and government officials. Police pledged to shut down clinics providing abortions illegally and on Thursday arrested a woman whom they accused of performing abortions and delivering the fetuses to the temple for cremation. She said she had transported the fetuses from several clinics, and claimed that models and actresses were among her clients. (See pictures of Bangkok, the capital of gridlock.)

Though abortion is still illegal in Thailand, there are exceptions in cases of rape, incest, a threat to the mother’s physical or psychological health or if the mother is underage. Nonetheless, according to Professor Kamheang Chaturachinda, president of the Women’s Health and Reproductive Rights Foundation of Thailand, some estimates say 300,000 to 400,000 abortions are performed each year in the nation of 67 million people, and because most are performed in illicit circumstances, they are unsafe, he says.

“The crackdown will not deter women who need abortion. It will, however, drive the price of abortion up, and cause more complications and deaths to women in the hands of these quacks,” Kamheang says. “Definitely, the poor and marginalized women will suffer greatly. And the Thai national health program will also pay more to care for these suffering women from complications arising from unsafe abortion.” Montri Pekanan, head of the Planned Parenthood Association of Thailand, also says the procedure’s legal status is endangering women. “We get so many women at our clinic who are suffering from complications from illegal abortions,” he says. “The personnel at those clinics are not qualified or licensed.” (See the most common hospital mishaps.)

Last week’s events have reopened the conversation about abortion’s legal status in Thailand. In a 2004 book titled Abortion, Sin and the State in Thailand, Andrea Whittaker wrote that abortion in Thailand “challenges the Kingdom’s most cherished images and stereotypes about itself, especially those that present Thailand as a Buddhist state … where women enjoy a high status and equality.” As a result, she says, Thai women’s advocacy groups have struggled to convince authorities of the health implications of the current policy. Both Montri and Kamheang say Thai women should have the right to choose and abortion should be legal. “There is public support for it, but it never passes in parliament,” Montri says. “Lawmakers don’t want to be called baby killers.” On Friday, Prime Minister Abhisit Vejjajiva said Thailand’s abortion laws were flexible enough as they are now and that he would not change them.

Reproductive-rights advocates say the police crackdown will do little to solve the problem, as there are too many clinics performing the service in the capital, and police will never be able to identify them all. Both Montri and Kamheang say a better path forward to reduce the number of women seeking illegal abortions would be to increase sex-education and pregnancy-prevention campaigns.

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